Provider Demographics
NPI:1962826826
Name:BOOTH, BRENDA B (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:B
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:B
Other - Last Name:DUERK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:224 OAKDALE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-2846
Mailing Address - Country:US
Mailing Address - Phone:440-986-6550
Mailing Address - Fax:
Practice Address - Street 1:1885 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-2551
Practice Address - Country:US
Practice Address - Phone:440-233-2271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 4265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist